Two parents whose baby died due to one episode of neglect had an "explicit pact" between them to never divulge dad's drug use, an inquest heard. This meant there was no opportunity for health workers to intervene in respect of the risk the parents posed to son Hunter White because of Adam White's undisclosed habitual use of cannabis.
Social care were aware of mum, Terri Walters, use of drugs and how she presented as someone who had an occasional monthly "blow-out" before he was born. But, in reality, her substance misuse was habitual and problematic.
Walters, 32, had "pick marks" on her skin indicative of itchiness from the constant misuse of illegal drugs.
READ MORE: Dad spared jail over neglect says he let his baby son down
Adam White's drug use was not known or "reasonably discoverable", said Gordon Clow, assistant coroner for Nottingham and Nottinghamshire, who recorded a short narrative conclusion into the death of 18-day-old Hunter, who died in his father's care.
And he said: "There was an explicit pact between the parents to never divulge Hunter's father's drug misuse".
In the early hours of July 10, 2020, little Hunter was found dead at Kingsway Gardens, Hucknall, where he lived with mum. Mr Clow, after hearing three days of evidence, said the baby's mother knew his father had taken drugs too but nonetheless left Hunter in his care.
The arrangement had been for dad to sleep on the sofa and for Hunter to sleep in his moses basket. After Hunter was fed, Adam White lay on the sofa watching television and put his son on his chest facedown.
Adam White did not rouse when Hunter slipped off his chest, and "this would not have occurred if he had avoided co-sleeping arrangements", said the coroner. "Had he not previously used cannabis, he may not have slept with Hunter and may have roused when Hunter slipped off his chest".
Hunter, who was on a child protection plan before birth, had slipped between his dad's abdomen and the back of the sofa. Hunter was not able to reposition himself and breathe and asphyxiated and died.
"His father woke after his death, shortly before 5.36am", added Mr Clow. "He called an ambulance and attempted CPR but Hunter was already dead".
The inquest also heard that after a social worker left their home the day before, the police investigation revealed Adam White - who social care had assessed to be the better carer than the mother - bought cocaine for his now ex-partner Walters, and cannabis.
In police interview plumber White, 45, of Foxhill Road East, Carlton, admitted he smoked cannabis that evening. Walters' account of her cocaine use misuse (the night before) was inconsistent, added Mr Clow.
Cocaine packages were found in her bedroom and residue. Test showed she had a significant quantity of cocaine in her system and had taken cannabis that night. Mr Clow said that the consumption of illicit drugs had "compromised" their ability to offer a safe sleeping arrangement for their new baby.
Neither parent intended his death but both had pleaded guilty to cruelty by way of neglect after he died due to their previous drug use. The cause of death was positional asphyxia arising from unsafe sleeping arrangements.
Safe sleeping advice had been given repeatedly to the parents. One of the greatest risks of sudden infant death syndrome is co-sleeping after the consumption of substances.
Now there is a revised "neglect tool kit" which is evidence based to build on and prove if there is a level of neglect. A "safe sleep assessment tool" has been introduced - something which is submitted to social care.
Now it makes clear in the child protection plan that the risk factor is there and it is addressed in the plan moving forward.
Walters and White were not required to attend the hearing in Nottingham but can request a copy of the evidence heard. White previously told Nottinghamshire Live about his son. He said: "He was a beautiful little baby...just his dad let him down, didn't he? I have five kids. I remember it all but I don't want to talk about it".
Laurence Jones, Service Director, Commissioning and Resourcing at Nottinghamshire County Council said: “We acknowledge the finding of the coroner in relation to the sad death of Hunter and his conclusion that whilst it would not have prevented Hunter’s death, he is concerned that processes in place in 2020 did not lead to clear expectations being placed on his parents.
“We will be providing a positive response to the coroner’s request for evidence that this has been addressed, in the timescale given, to provide further reassurance about practice improvements in this area.”
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